As manual therapy professions continue to grow, the biopsychosocial (BPS) healthcare model has been embraced particularly by practitioners of a holistic mindset, because of its potential for a more nuanced and compassionate whole-person approach. Yet, 50 years after its emergence, it has not seen the success some may have hoped for.
In Part 1 of this series (March/April 2021, page 42, massageandbodyworkdigital.com/i/1338685-march-april-2021/44), I highlighted the development of the new discipline of narrative medicine that aims to achieve what the BPS model has been unable to, explaining why it is nothing less than a revolution set to rewrite the relationship between biomedicine and holistic health care. In this installment, I summarize and compare the principles of narrative-based, evidence-based, and BPS practice in the context of manual therapy in particular.
The BPS Model and Pain Science
Conceptualized in the 1970s, the BPS approach to assessment and treatment has reshaped the majority of international medical curricula, and beyond the biomedical disciplines it has enjoyed considerable uptake in physiotherapeutic settings.1 This approach emerged in an effort to counter a fresh swing toward reductionist thought in the biomedical sciences by addressing the whole patient and remedying specific biomedical shortcomings—particularly the assumption that there must always be a pathological cause of disease, and that by uprooting it, health will be regained. The focus here is on pathology, rather than attempting to understand the spectrum of contributing factors resulting in illness.2
The BPS model aims for a more holistic approach originating in systems theory, taking the person’s psychological, social, and cultural influences into account when assessing and treating a complaint.3 It further differentiates disease (with a pathological cause) from illness (the absence of wellness that may not have a biomedical root pathology). Factors such as social, lifestyle, or mental adjustments made to accommodate its effects (such as guarding an injured limb or coming to terms with loss of functionality) should not be pathologized or criticized. Rather, the therapist should seek to understand the context of these adaptations. Key to the original formulation of the BPS model is a reexamination of the concept of disease: “Disease cannot be defined on the basis of the function of physicians, which is a social and institutional phenomenon.”4
The BPS model allows a tailored approach that “places the disease back into the patient”5 (as opposed to the textbook) and has been demonstrated to have significantly greater efficacy than surgery particularly in the assessment and management of chronic pain. Some evidence suggests a multidisciplinary BPS approach is more effective than physical hands-on treatment,6 which does not clash with the evidence-based medicine model but improves on it when the two are integrated and correctly implemented.7
In practice, the BPS approach places significant emphasis on the intake interview with a broader range of questions than in traditional history taking, while the therapist pays particular attention to the sociocultural and psychological components of a patient’s responses in developing a treatment plan. This approach includes reeducating the patient around their perceptions of pain. In the context of physical therapy, this has been dubbed the “first step in pain neuroscience education,” wherein the personalized treatment plan should include “a proper explanation of the neurophysiology of pain and the biopsychosocial interactions in an interactive and patient-centered manner.”8 The goal of BPS is to help patients understand their condition in a way that is relevant to their individual context, moving away from traditional biomedical models that have been demonstrated to have adverse effects on a patient’s progress.
According to the current literature, the key principles of pain science on which this approach rests are: Pain does not necessarily reflect the state of tissue. The degree of pain felt does not accurately reflect the actual degree of tissue damage. And the plasticity of the nervous system allows retraining and treatment.9 To effectively use the last of these, development of a collaborative relationship is necessary to achieve lifestyle and behavioral changes. These principles have strongly influenced priorities in pain research and have greatly impacted both physiotherapy and related professions.10
Criticisms of the BPS model focus largely on the difficulty of implementation. As noted by researchers and clinicians alike, it has not been effectively integrated into medical education as a technique, nor has it been “effectively translated into the practical applications demanded by these domains.”11 These issues are echoed in the most recent feedback from physical therapy in particular, where many therapists express a lack of confidence or skills deficit in implementing the BPS model.12 Furthermore, as shown in a recent study, although interdisciplinary multimodal approaches to chronic pain with a BPS component have been demonstrated to be effective in the context of physical therapy, the evidence in favor of pain neuroscience education directed at patients remains conflicted, though this may be due to how it is implemented.13
It is clear from the extensive literature exploring BPS in physiotherapy that pain neuroscience education is becoming firmly established, and evidence so far suggests it is moderately effective—more so when integrated within an interdisciplinary intervention model.14 This has, in turn, led to discussion of whether manual treatment will become ever scarcer, since the aim of pain neuroscience education is to refocus attention from the painful tissue to the neurological interpretation of stimuli resulting in nociception.15 Some studies have built strong cases for the integration of both approaches.16 Other studies focus more strongly on the educational component aimed at altering perceptions of pain and behaviors.17
An important recent editorial argues strongly for a reexamination and improvement of manual therapy education overall, reiterating what to some may be obvious: “The essential skill of listening and correctly analyzing the patient’s account of their experience is a foundational skill within multiple paradigms of MT practice . . . The opportunity to better communicate how the ‘bio’ of MT integrates within the ‘psychosocial’ of the intervention model has arrived. Now is the time to update outdated teaching models in MT education and provide leadership for integration of other interventions within the BPS model.”18 It is important to note this is not a call for the abolition of hands-on practice; rather, it is a call to better place the modalities in the therapist’s toolbox with correctly implemented BPS as a decision-making road map.
Patient-Clinician Therapeutic Alliance
The therapeutic alliance (also known as working alliance) refers to the working relationship or “bond” that develops between patient and clinician. With roots in psychodynamics, the concept was expanded to encompass all therapeutic disciplines, and has generally been seen as vital for a successful outcome, client retention, and critically, public trust. At the heart of the therapeutic alliance is trust and a person-centered approach. Specifically, “The concept of bonds embraces the network of positive personal attachments between client and therapist that includes issues such as mutual trust, acceptance, and confidence.”19
This therapeutic relationship has undergone many iterations and shifts to its dynamic over the centuries, and as noted earlier, in the past a strongly paternalistic and authoritarian model dominated biomedicine, largely depersonalizing the patient while ascribing power to the expert physician, reflected both in wider society and the consultation room. Evidence-based medicine brought more physician accountability but few changes to this model until BPS improved it considerably. With the new emphasis on psychosocial factors, it now became the task of therapists to apply their expertise in a way that acknowledges the patient’s psychosocial and cultural context. This is frequently referred to as person-centered medicine.
Yet, the therapeutic alliance of BPS may not be as person-centered as it might seem, nor the application of pain neuroscience education, despite the best of intentions.20 It is revealing to observe just how many studies on the integration of behavior modification programs in health care focus on how to facilitate their acceptance and uptake among patients resisting such interventions.21 In short, despite warnings to avoid such an approach,22 the discussion frequently slips into querying how to convince patients you know better and intend to educate them out of their ignorance for their own good. One cannot but wonder whether this contravenes the desired goal of ethical integrity—a point argued in depth by proponents of narrative-based medicine—with a host of supporting literature.
Classical medical training does not deal with this in detail; rather, it is the humanities once again where ethics are interrogated to tease out meaning. If patient autonomy is to be taken seriously, then one cannot hold to double standards. And if clinicians are fallible humans despite the best of intentions, can we be certain their expert opinions are indeed objective? Or might it be true that we are all “formed in relation to others and by language and social structures?”23 In such a case, who is the expert on our patient—the literature, our training, or the patient themselves?
Modern ethical principles suggest we should acknowledge the impossibility of certainty regarding our own judgment, recommending both humility and vulnerability as counterweights to the therapeutic encounter, especially in view of the inherent inequality of the medical context.24
Narrative Medicine: What It Isn’t
Dualism is a difficult habit to think our way out of, and despite positive research on BPS when implemented through interdisciplinary interventions, the separation of the “bio” from the “psychosocial” remains a common problem. One common trap is “essentializing” traits, whereby a member of a particular culture may be subconsciously stereotyped according to gender, race, age, community, or any number of other subcategories. Though we may assume that by acknowledging an individual’s cultural context we are demonstrating respect, we may in fact be imposing our own perceptions on them, thus doing the exact opposite. Equally, expecting that a specific stimulus will derive a specific response (regardless of the evidence) falls into the same trap and cannot have a holistic result.25 This may be the source of frustration expressed by many physical therapists when they find that their best attempts at applying BPS fall short.26
Similar issues apply to pain neuroscience education, compounded by the role of inequality, since “the power is all on one side.”27 An individual sits in your clinic, having experienced perhaps months of pain. They may feel some form of shame, frustration, or even anger at their situation, and they don’t know the way forward, but they know they want it gone. They’re not sure you can help them, but they’ve come in hope, and perhaps a little fear. For some who are wired that way, offering them education will indeed help; they may grasp at it. But some will feel intimidated and thus shamed, or insulted, or simply exhausted. They don’t all want a snazzy PowerPoint and colorful lectures on gate control theory and neuroplasticity. They couldn’t give a damn whether you subscribe to the idea that manual therapy is only skin deep or how many weekend courses you’ve taken in some cool trademarked modality. If they’ve walked in hoping for half an hour of hands-on focus on their painful back, or neck, or knee, connecting the therapeutic encounter with touch or movement in some form, then a lecture, however gently delivered, isn’t going to do that for them. They don’t care about your meticulously curated evidence base regarding manual therapy versus interdisciplinary intervention, nor what checkboxes you’re trying to tick.
It should go without saying that basic ethics along with scope of practice must be adhered to above all else, and a discussion of placebo is also needed here, but the point is that if you want to convince them otherwise, then you first need to “get inside their heads” to work out what the way forward might be. Knowing your audience is a fundamental principle of good teaching—this does not come about only through the standard interview, but by listening to their unfiltered narrative. Thus, according to the principles of narrative medicine, before talking, you need to recalibrate your own position first, and listen more closely than ever before.28 The act of “diagnostic listening” allows the therapist to acknowledge more fully and help the patient face often unanswerable questions. If they do not, then the “resultant diagnostic workup might be unfocused and therefore more expensive than need be, the correct diagnosis might be missed, the clinical care might be marked by noncompliance and the search for another opinion, and the therapeutic relationship might be shallow and ineffective.”29
Narrative medicine flips the clinical encounter by allowing the patient’s narrative to speak for itself, and using all the faculties of the practitioner to meet them as equals:
“The narrative ethicist is trained to pay attention to what patients, families, and clinicians say and write about the situation. From literary, linguistic, or social science disciplines, the ethicist learns to recognize the genre, point of view, metaphor, diction, and temporality of a conversation or a written text to understand what the story’s content might in fact tell . . . What does this practice of narrative ethics look like? To exercise compassion in adjusting treatment to the particularities of this patient’s life story, to remove the blindfold of a universalist principle of justice and attend to a patient’s specific needs.”30
Exercising compassion requires embracing uncertainty—not easy to do when all of your training has focused on the opposite. Critically, it means ceasing to consider some patients “difficult” because of noncompliance—if that is a therapist’s inner thought, then they may need to reconsider their approach altogether. There is a freedom and a sharing of the burden of responsibility in perceiving patients as people whose narratives unlock the path to improvement. Let us not forget that uncertainty is part and parcel of clinical reality, both in the emergency room, the critical care unit, chronic pain situations, and the everyday clinic. In all those contexts, patients come in and tell their stories, but as demonstrated in the opening quote, garden-variety health-care training teaches you to pick out only those details focused on pathology (the “bio” of BPS), and in so doing, to ignore the individual—which amounts to more than the “psychosocial.”
The keys to building that therapeutic alliance are embedded in the details normally discarded. Learning to use them does not require training in psychoanalysis or psychology, and importantly, it should not be identified with directive coaching or counseling techniques such as motivational interviewing. This may sound counterintuitive, but introducing intentional direction before the patient requests it negates the purpose of the technique.
Narrative-based medicine requires a refreshed focus on the elements of the story that will tell you the relationship of the individual to their condition, as well as to their BPS context beyond the essentialist paradigm of culture, social class, race, gender, age, and so on. Attention to nuance, such as choice of words, coherence of the timeline, or whether there is a chaotic quality to their storytelling, will reveal much about the path to follow. The exploration of these elements should not be conducted with a view to forcing—or even directing—change but in holding space for the patient, and for the therapist to make them part of the dialogue and deliberation when examining the therapeutic options at hand. The methods for achieving shift in focus are embedded in the skill sets of the humanities disciplines—which can be learned and applied within normal history taking, with multiple potential rewards for both clinician and patient.
Biomedical educators have long been calling for the further integration of humanities-based learning into medical curricula because of the phenomena outlined above, compounded by a form of detachment that tends to appear as a result of medical training.31 Key aims of this training are to facilitate the trainee physicians’ self-awareness in their role, to maintain and implement more humanistic approaches to practice, and to build resilience by working through often dark and difficult scenarios of pain, illness, failure, and disaster in the safe environment of the literary text long before they are faced with them in their clinic. Aside from developing better listening skills and resilience, there is even qualitative evidence that training and long-term familiarization with literary fiction and visual art creates neurobiological change that affects our ability to mentalize (perceive and understand one’s own behavior and that of others, maintaining a not-knowing approach).32 These are techniques well known to humanities scholars and educators, and it is impressive to note how closely interdisciplinary teams of educators have worked to develop these curricula, as the results indeed appear very promising.33
“But . . . I’m Not a Humanities Scholar!”
The practice of narrative medicine by active clinicians requires some additional training, but it does not require all clinicians to suddenly become literary scholars or psychoanalysts. The training involved is no more or less than that demanded by any continuing education course. If you already have a liberal arts background, then it will be all the easier to apply existing skills. If not, it is simply a new modality that can transform your practice. What the practice of narrative medicine does require is an openness in mindset—and a long-term commitment to reading a bit of fiction, as one-shot approaches are ineffective.
The practice becomes systematized by exporting specific transferable skills delivered through a workshop-style series of training sessions where educators guide practitioners through the process of engaging with the narrative form through close reading and writing, and learning to observe, interpret, and respond to specific elements that will prepare them for “deep listening” in the clinical setting. The goal is to use patient narratives systematically in the therapeutic encounter, which allows the clinician to apply their art and science based on the meaning of the experience to that patient.
The meanings patients ascribe to their experience of illness help unlock the path to supporting them through it. “Close” reading and listening is a skill that can be applied far beyond the literary text, and in the case of a patient’s narrative, allows the clinician to see beyond the “bio,” as well as the too normative “psychosocial” of the BPS model. As it provides a holistic view of the individual, it is not entirely relativistic either: “It is the capacity of literature to embody the reality of being in the world that gives narrative practices in health care their powers.”34
The narratives delivered by the patient can offer insight into, for example, whether (and crucially, why) they are likely to comply with and maintain new lifestyle habits; what deep-thinking patterns require a different approach to well-meaning imposition of impersonal clinical assessment. By offering a patient the space to share their own narrative, and the sense that their experience of illness is actually seen and respected, the foundations for trust are laid, and much deeper insight into the potential ways forward can be gleaned. This trust cannot be achieved by maintaining the subject-object relationship. Importantly: “Even at the ends of life . . . it is a powerful and respectful way for humans to meet . . . to tolerate doubt and fear, to accept help.”35 For those who feel that empathy, mindfulness, and person-centered practice should be at the heart of health care, this approach offers the tools to implement it with.
The narrative process begins with what some clinicians are calling pathography—“a written, nonfiction account of illness”36 elicited from the patient, and some researchers are also exploring the use of sketching and drawing along the same principles, in what is being termed graphic medicine.37 For those wondering why such skills should even be considered in a medical setting, the answers are compelling: “Frequently, students coming into medical school believe that they can simply learn enough to be certain—that banishing ambiguity and doubt, and thereby remaining less touched by the emotion of the work, is a matter of how much you take in and how hard you work . . .”38 Further this with reference to anatomical knowledge: “In knowing the cadaver in such intimate detail we believe that we are acquiring the knowledge to overcome death.”39 Important as this knowledge is, it should not overshadow the reality of the individual.
For those who are not readers by choice, it is important to remember the goal—to learn the skill of seeing with fresh eyes and to develop a “mode of attention.”40 It is a highly interactive and participatory process that has been demonstrated to convince the most skeptical of participants.41 As the practitioner observes their own “cognitive, affective, and characterological” thought processes during this training, they understand how they themselves extract meaning, how they interpret what they read and hear,42 and this is the true definition of mindful practice. Once mindfulness is established, the method involves applying a sequence of questions (internally) to the patient’s narrative in order to complete the remaining steps—with the goal being to develop a treatment plan that includes equal patient input. The therapist will still have extracted the information necessary to assess the biomedical standpoint, but in such a way as to create a symmetry of power between therapist and patient, increasing the likelihood of a positive outcome. If ever there were a case for taking a fresh look at how evidence-based medicine is implemented, this one is particularly compelling, particularly as the evidence base for narrative-based medicine continues to grow rapidly.43
Osteopathy Knew This Already . . .
I am certain that any osteopaths reading will by now either be smiling or hopping with frustration. The ethical principles—and many of the inherent practices within narrative medicine—were embedded within osteopathic practice before bioethics was a discipline. Indeed, the old debates on the body-mind connection earned osteopathy derision from certain quarters for many years, and continue to fuel misperceptions even now that biomedicine has acknowledged that connection. Though osteopathic education and practice on the two sides of the Atlantic differ in many ways, the core principles do not. In that context, the appearance of narrative medicine may be seen as gratification on the one hand and as too little, too late on the other. From my perspective as a humanities scholar with close ties to these professions, the acknowledgment of narrative medicine’s legitimacy appears to be an immense opportunity to finally begin building bridges.
The history of how and why the biomedical disciplines and the integrative health disciplines found themselves on opposite sides of the evidence-based medicine fence requires care, nuance, and, dare I say, a historian’s insight. Yet, it does not seem constructive to revisit old offenses. The words of poet T. S. Eliot could sum up the story I have told here: “And the end of all our exploring / Will be to arrive where we started / And know the place for the first time.”44
For complex reasons, the underlying principles of these disparate approaches to health care are beginning to converge. The goal is that of better serving people who need it; it has been said that narrative medicine “as a source, represents something clinically relevant to numerical data of an arterial blood gas. As an instrument, requiring skillful technique for its implementation, like a scalpel.”45
It has equally been observed that criticisms against application of narrative-based medicine are limited to matters of time management in the acute clinical context, which do require further work, but they do not affect its capacity for effective implementation in the private or specialist clinic. Therefore, I would venture that there is much to be gained from engaging with the very active outreach centers that deliver both and full-length courses in narrative-based medicine, as its foundational, ethical, and practical principles form the ideal bridge between the drive for evidence-based practice and a truly compassionate, humanistic approach to health care.
Neither empathy nor compassion can be instilled or forced. But, in those willing to apply it, narrative-based medicine may be facilitated through attitude and skills development.46 As these practices spread across biomedical disciplines, it might be proposed that all who wish to practice ethically and effectively would benefit by exploring them.
Looking Ahead
Part 3 of this series examines a case study and offers exercises to demonstrate the application of the methods described in a manual therapy context. Part 4 consists of a more detailed critical appraisal of narrative medicine and its companion graphic medicine, with attention to their potential for implementation in the manual therapy professions in general, and massage therapy in particular.
Beyond the potential benefit to individual practice, in view of the current restrictions due to the COVID-19 pandemic, this information may provide a valuable path of exploration and training for manual therapists who are looking for ways to pivot professionally. The information may also be a valuable way to bridge evidence-based medicine practice with current developments.
Notes
1. Marilys Guillemin and Emma Barnard, “George Libman Engel: The Biopsychosocial Model and the Construction of Medical Practice,” in The Palgrave Handbook of Social Theory in Health, Illness, and Medicine, ed. Fran Collyer (London: Palgrave Macmillan, 2015), 236–50, https://doi.org/10.1057/9781137355621.
2. Derick T. Wade and Peter W. Halligan, “Do Biomedical Models of Illness Make for Good Healthcare Systems?” BMJ 329, no. 7479 (December 2004): 1398–1401, https://doi.org/10.1136/bmj.329.7479.1398; Marilys Guillemin and Emma Barnard, “George Libman Engel: The Biopsychosocial Model and the Construction of Medical Practice,” 240.
3. Marilys Guillemin and Emma Barnard, “George Libman Engel: The Biopsychosocial Model and the Construction of Medical Practice,” 238.
4. George L. Engel, “A Unified Concept of Health and Disease,” Perspectives in Biology and Medicine 3, no. 4 (Summer 1960): 459–85, https://doi.org/10.1353/pbm.1960.0020.
5. Bradley K. Weiner, “Spine Update: The Biopsychosocial Model and Spine Care,” Spine 33, no. 2 (January 2008): 219–23, https://doi.org/10.1097/BRS.0b013e3181604572.
6. Steven J. Kamper et al., “Multidisciplinary Biopsychosocial Rehabilitation for Chronic Low Back Pain: Cochrane Systematic Review and Meta-Analysis,” BMJ 350 (February 2015): h444, https://doi.org/10.1136/bmj.h444.
7. Robert C. Smith et al., “An Evidence-Based Patient-Centered Method Makes the Biopsychosocial Model Scientific,” Patient Education and Counseling 91, no. 3 (June 2013): 265–70, https://doi.org/10.1016/j.pec.2012.12.010.
8. Amarins J. Wijma et al., “Clinical Biopsychosocial Physiotherapy Assessment of Patients with Chronic Pain: The First Step in Pain Neuroscience Education,” Physiotherapy Theory and Practice 32, no. 5 (May 2016), https://doi.org/10.1080/09593985.2016.1194651; Jaime Guzman et al., “Multidisciplinary Rehabilitation for Chronic Low Back Pain: Systematic Review,” BMJ 322, no. 7301 (June 2001): 1511–16, https://doi.org/10.1136/bmj.322.7301.1511.
9. Robert J. Gatchel and Krista J. Howard, “The Biopsychosocial Approach,” Practical Pain Management 8, no. 4 (May 2008), www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach.
10. Romy Parker and Victoria J. Madden, “State of the Art: What Have the Pain Sciences Brought to Physiotherapy?” South African Journal of Physiotherapy 76, no. 1 (February 2020): a1390, https://doi.org/10.4102/sajp.v76i1.1390.
11. Marilys Guillemin and Emma Barnard, “George Libman Engel: The Biopsychosocial Model and the Construction of Medical Practice,” 242; Joseph Herman, “The Need for a Transitional Model: A Challenge for Biopsychosocial Medicine?,” Families, Systems and Health 23, no. 4 (January 2005): 372–76, https://doi.org/10.1037/1091-7527.23.4.372; D. B. Seaburn, “Is Going ‘Too Far’ Far Enough?,” Families, Systems and Health 23, no. 4 (January 2005): 396–99, https://doi.org/10.1037/1091-7527.23.4.396.
12. Aoife Synnott et al., “Physiotherapists May Stigmatise or Feel Unprepared to Treat People with Low Back Pain and Psychosocial Factors that Influence Recovery: A Systematic Review,” Journal of Physiotherapy 61, no. 2 (April 2015): 68–76, https://doi.org/10.1016/j.jphys.2015.02.016; Aoife Synnott et al., “Physiotherapists Report Improved Understanding of and Attitude Toward the Cognitive, Psychological, and Social Dimensions of Chronic Low Back Pain after Cognitive Functional Therapy Training: A Qualitative Study,” Journal of Physiotherapy 62, no. 4 (October 2016): 215–21, https://doi.org/10.1016/j.jphys.2016.08.002; Jenny Alexanders, Anna Anderson, and Sarah Henderson, “Musculoskeletal Physiotherapists’ Use of Psychological Interventions: A Systematic Review of Therapists’ Perceptions and Practice,” Physiotherapy 101, no. 2 (June 2015): 95–102, https://doi.org/10.1016/j.physio.2014.03.008; Mukul Singla et al., “Physiotherapists’ Assessment of Patients’ Psychosocial Status: Are We Standing on Thin Ice? A Qualitative Descriptive Study,” Manual Therapy 20, no. 2 (April 2015): 328–34, https://doi.org/10.1016/j.math.2014.10.004.
13. M. Richter et al., “Effect of Additional Pain Neuroscience Education in Interdisciplinary Multimodal Pain Therapy on Current Pain. A Non-Randomized, Controlled Intervention Study,” Journal of Pain Research 16, no. 13 (November 2020): 2947–57, https://doi.org/10.2147/JPR.S272943; Tom Sanders et al., “Biopsychosocial Care and the Physiotherapy Encounter: Physiotherapists’ Accounts of Back Pain Consultations, BMC Musculoskeletal Disorders 14, no. 65 (February 2013), https://doi.org/10.1186/1471-2474-14-65.
14. Anneleen Malfliet et al., “Blended-Learning Pain Neuroscience Education for People with Chronic Spinal Pain: Randomized Controlled Multicenter Trial,” Physical Therapy 98, no. 5 (May 2018): 357–68, https://doi.org/10.1093/ptj/pzx092.
15. Emilio J. Puentedura and Timothy Flynn, “Combining Manual Therapy with Pain Neuroscience Education in the Treatment of Chronic Low Back Pain: A Narrative Review of the Literature,” Physiotherapy Theory and Practice 32, no. 5 (November 2015): 408–14, https://doi.org/10.1080/09593985.2016.1194663; Gwendolen Jull and Ann Moore, “Hands On, Hands Off? The Swings in Musculoskeletal Physiotherapy Practice,” Manual Therapy 17, no. 3 (June 2012): 199–200, https://doi.org/10.1016/j.math.2012.03.009; Rob A. B. Oostendorp, “Credibility of Manual Therapy is at Stake: Where Do We Go From Here?,” Journal of Manual and Manipulative Therapy 26, no. 4 (August 2018): 189–92, https://doi.org/10.1080/10669817.2018.1472948; Adriaan Louw et al., “The Efficacy of Pain Neuroscience Education on Musculoskeletal Pain: A Systematic Review of the Literature,” Physiotherapy Theory and Practice 32, no. 5 (July 2016): 332–55, https://doi.org/10.1080/09593985.2016.1194646; G. Lorimer Moseley, “Joining Forces—Combining Cognition-Targeted Motor Control Training with Group or Individual Pain Physiology Education: A Successful Treatment for Chronic Low Back Pain,” Journal of Manual and Manipulative Therapy 11, no. 2 (July 2013): 88–94, https://doi.org/10.1179/106698103790826383; Lorimer Moseley, “Unraveling the Barriers to Reconceptualization of the Problem in Chronic Pain: The Actual and Perceived Ability of Patients and Health Professionals to Understand the Neurophysiology,” Journal of Pain 4, no. 4 (May 2003): 184–89, https://doi.org/10.1016/s1526-5900(03)00488-7; Cory Blickenstaff and Neil Pearson, “Reconciling Movement and Exercise with Pain Neuroscience Education: A Case for Consistent Education,” Physiotherapy Theory and Practice 32, no. 5 (November 2015): 396–407, https://doi.org/10.1080/09593985.2016.1194653.
16. Adriaan Louw, Jo Nijs, and Emilio J. Puentedura, “A Clinical Perspective on a Pain Neuroscience Education Approach to Manual Therapy,” Journal of Manual and Manipulative Therapy 25, no. 3 (May 2017): 160–68, https://doi.org/10.1080/10669817.2017.1323699.
17. Lynn Hackstaff, Carol Davis, and Lynne Katz, “The Case for Integrating Behavior Change, Client-Centered Practice, and Other Evidence-Based Models into Geriatric Care Management,” Social Work in Health Care 38, no. 3 (January 2003): 1–19, https://doi.org/10.1300/J010v38n03_01.
18. William H. Kolb et al., “Editorial: The Evolution of Manual Therapy Education: What Are We Waiting For?” Journal of Manual & Manipulative Therapy 28, no. 1 (January 2020): 1–3, https://doi.org/10.1080/10669817.2020.1703315.
19. Adam O. Horvath and Lester Luborsky, “The Role of the Therapeutic Alliance in Psychotherapy,” Journal of Consulting and Clinical Psychology 61, no. 4 (September 1993): 561–73, https://doi.org/10.1037//0022-006x.61.4.561.
20. Ina Diener, Mark Kargela, and Adriaan Louw, “Listening is Therapy: Patient Interviewing from a Pain Science Perspective,” Physiotherapy Theory and Practice 32, no. 5 (June 2016): 356–67, https://doi.org/10.1080/09593985.2016.1194648.
21. Lynn Hackstaff, Carol Davis, and Lynne Katz, “The Case for Integrating Behavior Change, Client-Centered Practice, and Other Evidence-Based Models into Geriatric Care Management.”
22. Adriaan Louw, Emilio J. Puentedura, and Kory Zimney, “Teaching Patients about Pain: It Works, But What Should We Call It?” Physiotherapy Theory and Practice 32, no. 5 (July 2016): 328–31, https://doi.org/10.1080/09593985.2016.1194669.
23. Maura Spiegel and Danielle Spencer, “Accounts of Self: Exploring Relationality through Literature,” in The Principles and Practice of Narrative Medicine, ed. Rita Charon et al. (London: Oxford University Press, 2017), 29; Judith P. Butler, Giving an Account of Oneself (New York: Fordham University Press, 2005).
24. Maura Spiegel and Danielle Spencer, “Accounts of Self: Exploring Relationality through Literature,” 29–30.
25. John W. Murphy et al., Narrative Medicine and Community-Based Health Care and Planning (Switzerland: Springer, 2017), 7–8.
26. Marilys Guillemin and Emma Barnard, “George Libman Engel: The Biopsychosocial Model and the Construction of Medical Practice.”
27. Craig Irvine and Rita Charon, “Deliver Us from Certainty: Training for Narrative Medicine,” in The Principles and Practice of Narrative Medicine, ed. Rita Charon et al. (London: Oxford University Press, 2017), 114.
28. Craig Irvine and Rita Charon, “Deliver Us from Certainty: Training for Narrative Medicine,” 119–20.
29. Rita Charon, “Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust,” Journal of the American Medical Association 286, no. 15 (October 2001): 1897–1902, https://doi.org/10.1001/jama.286.15.1897.
30. Craig Irvine and Rita Charon, “Deliver Us from Certainty: Training for Narrative Medicine,” 120.
31. Rita Charon, “Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust”; R. Fox and H. Lief, “Training for ‘Detached Concern,’ ” in The Psychological Basis of Medical Practice, ed. H. Lief (New York: Harper & Row, 1963): 12–35; N. Hermann, “Creativity: What, Why, and Where?” in The Principles and Practice of Narrative Medicine, Charon et al. (London: Oxford University Press, 2017), 217; Newell, Interviewing Skills for Nurses and Other Health Care Professionals (New York, Routledge, 1994); Mack Lipkin, Jr., Samuel M. Putnam, and Aaron Lazare, The Medical Interview (New York: Springer-Verlag, 1995); Eric J. Cassell, Talking with Patients (MIT Press, 1985).
32. Dalya Samur, Mattie Tops, and Sander L. Koole, “Does a Single Session of Reading Literary Fiction Prime Enhanced Mentalising Performance? Four Replication Experiments of Kidd and Castano (2013),” Cognition and Emotion 32, no. 1 (July 2015): 130–44, https://doi.org/10.1080/02699931.2017.1279591; P. Matthijs Bal and Martijn Veltkamp, “How Does Fiction Reading Influence Empathy? An Experimental Investigation on the Role of Emotional Transportation,” PLOS One 8, no. 1 (January 2013): e55341, https://doi.org/10.1371/journal.pone.0055341; Roger C. Schank and Robert P. Abelson, “Knowledge and Memory: The Real Story,” in Advances in Social Cognition, ed. Robert S. Wyer, Jr. (New York: Psychology Press, 1995), 1–85; H. J. Welstead et al., “Mentalising Skills in Generic Mental Healthcare Settings: Can We Make Our Day-to-Day Interactions More Therapeutic?” BJPsych Bulletin 42, no. 3 (April 2018): 102–08, https://doi.org/10.1192/bjb.2017.29.
33. For early instances, see reference list in Rita Charon, Narrative Medicine: Honoring the Stories of Illness (New York: Oxford University Press, 2001). Also see the Gold Foundation database at www.gold-foundation.org/resources/#databases.
34. Craig Irvine and Rita Charon, “Deliver Us from Certainty: Training for Narrative Medicine,” 130.
35. Craig Irvine and Rita Charon, “Deliver Us from Certainty: Training for Narrative Medicine,” 130.
36. Susan Merrill Squier and Irmela Marei Krüger-Fürhoff, eds., “Introduction,” in PathoGraphics: Narrative, Aesthetics, Contention, Community (University Park: Pennsylvania University Press, 2020), 1–6, www.geisteswissenschaften.fu-berlin.de/friedrichschlegel/assoziierte_projekte/Pathographics/sl_2a_WHATis/index.html.
37. Michael J. Green and Kimberly R. Myers, “Graphic Medicine: Use of Comics in Medical Education and Patient Care,” BMJ 340: c863, https://doi.org/10.1136/bmj.c863; Ian Williams, “Why ‘Graphic Medicine?’ ” accessed January 18, 2020, www.graphicmedicine.org/why-graphic-medicine.
38. N. Hermann, “Creativity: What, Why, and Where?,” 217.
39. Pauline W. Chen, Final Exam: A Surgeon’s Reflections on Mortality (New York: Vintage, 2008), 8.
40. Peter Parisi, “Close Reading, Creative Writing, and Cognitive Development,” College English 41, no. 1 (September 1979): 57–67, https://doi.org/10.2307/376360.
41. Charon, “Close Reading: The Signature Method of Narrative Medicine,” 175.
42. Charon, “Close Reading: The Signature Method of Narrative Medicine,” 170.
43. See the Gold Foundation databases on humanism in health care at www.gold-foundation.org/resources/#databases.
44. T. S. Eliot, “Little Gidding,” in Four Quartets (New York: Harcourt, 1943), www.columbia.edu/itc/history/winter/w3206/edit/tseliotlittlegidding.html.
45. Liam Dwyer, “Does Narrative Medicine Have a Place at the Frontline of Medicine?” BMJ Medical Humanities Blog, May 30, 2017, https://blogs.bmj.com/medical-humanities/2017/05/30/does-narrative-medicine-have-a-place-at-the-frontline-of-medicine; David B. Morris, “Narrative Medicines: Challenge and Resistance,” The Permanente Journal 12, no. 1 (Winter 2008): 88–96, https://doi.org/10.7812/tpp/07-088.
46. Carol M. Davis, “What is Empathy, and Can Empathy Be Taught?,” Physical Therapy 70, no. 11 (December 1990): 707–11, https://doi.org/10.1093/ptj/70.11.707.
With 20 years in teaching and over a decade in journalism and academic publishing, Sasha Chaitow, PhD, is series editor for Elsevier’s Leon Chaitow Library of Bodywork and Movement Therapies and former managing editor of the Journal of Bodywork & Movement Therapies. Based between the UK and Greece, she teaches research literacy and science reporting at the University of Patras, Greece. She is also a professional artist, gallerist, and educator who exhibits and teaches internationally.